Navigate Shifting Reimbursement Criteria for Molecular Testing

At TELCOR, we’ve recently identified a notable shift in how molecular claims specifically associated with CPT code 87798, are being processed by Novitas.

Through extensive research and direct communication with payer representatives, it is clear this change is not tied to a newly published Local Coverage Determination (LCD). Instead, it reflects a broader reevaluation by CMS, with increased scrutiny being applied under the long-standing “reasonable and necessary” standard outlined in CMS Medicare IOM, Publication 100-02, Chapter 15, Section 1862(a)(1)(A) of the Social Security Act.

The potential impact is significant. For example, some laboratories previously billing CPT 87798 at higher volumes are now seeing a full denial of these transacions. This level of disruption underscores the importance of proactive monitoring and strategic response.

While TELCOR does not provide coding guidance, we strongly encourage laboratories to evaluate current billing practices in the context of these changes. Any adjustments must align with internal compliance standards and accurately reflect the services performed.

Visibility and adaptability within revenue cycle are critical. As payer behavior continues to evolve, organizations leveraging real-time insights and maintaining a proactive stance will be best positioned to mitigate risk and sustain financial performance.

TELCOR remains committed to partnering with our clients through these changes, ensuring no earned revenue is left behind.

- Sarah Stewart, Vice President, RCS